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Awareness & Sensitivity to Client’s Health Care Needs

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1 Awareness & Sensitivity to Client’s Health Care Needs
Competency 6: Loss, Grief, & Death Developed by: Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP

2 U.S. Department of Labor Grant
“This workforce solution was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use, by and organization and/or personal use by an individual or non-commercial purposes, is permissible. All other uses require the prior authorization of the copyright owner.”

3 Competency 6: Death & Dying
Define the stages & processes of death & dying & influences those stages have on clients & families List the emotional stages of grief that occur in death & dying List the needs of the dying client & their family List the different types of death & how they may affect the client & the family’s ability to move through the stages of death

4 Lifetime Losses & Grieving
Everyone experiences loss, grieving, & death at some time during his/her life. People may suffer loss of: Valued relationships through moving from one city or state to another, separation, divorce, or the death of a family member (parent, grandparent, sibling, spouse) or friend Changing life roles as they watch grown children leave home or retire from lifelong work, Employment or ability to drive a vehicle safely Valued material objects through theft, natural disasters Pets (Berman et al., p. 1081)

5 Loss in Health Care Settings
Healthcare workers interact with dying clients & their families or caregivers in a variety of settings from a death of an unborn child, to the adolescent victim of an automobile collision, to the elderly client who dies from a chronic illness There are many influences on the dying process: legal, ethical, religious, spiritual, biological, personal It is important that the healthcare worker provides sensitive, skilled, & supportive care to all those affected (Berman et al., p. 1081)

6 Loss in Health Care Settings
Healthcare workers encounter clients who may be experiencing grief to declining health, loss of a body part, terminal illness, or impending death of self or significant other, loss of function, loss of independence, In home healthcare or community, healthcare worker may work with clients grieving losses related to personal crisis (divorce, separation) or disaster (tornadoes, floods, fire) It is important to understand the significance of loss & develop an ability to assist clients as they work through the grieving process (Berman et al., p. 1081)

7 Loss Loss: The actual or potential situation in which something that is valued is changed & no longer available People can experience the loss of body image, a significant other, a sense of well-being, a job, personal possessions, or beliefs Illness & hospitalization often produce losses (Berman et al., p. 1081)

8 Death Death is a fundamental loss for the dying person & for those who survive Death can be viewed as the dying person’s final opportunity to experience life in ways that bring significance & fulfillment People experiencing loss search for the meaning of the event, & it is generally accepted that finding the meaning is needed in order for healing to occur However, persons can be well adjusted without searching for meaning, & even those who find meaning may not see it as an end point but rather an ongoing process (Berman et al., p. 1081)

9 Types of Losses Actual Loss: Loss that can be recognized by others
Perceived Loss: Loss experience by one person but cannot be verified by another Example: A woman who leaves her employment to care for her children at home may perceive a loss of independence & freedom Both actual & perceived losses can be anticipatory loss Anticipatory Loss: Loss that is experienced before the loss actually occurs Example: A woman whose husband is dying may experience the actual loss in anticipation of his death (Berman et al., p. 1082)

10 Types of Losses Loss can be viewed as situational or developmental
Developmental Losses: Losses that occur during the process of normal development, such as grown children leaving home, retirement from a career, death of aged parents (these generally can be anticipated & prepared for) Many sources of loss: Loss of an aspect of self: a body part, a physiologic function (no longer able to bear a child) or a psychological attribute; loss of an object external to oneself; separation from an accustomed environment; loss of a loved or valued person (Berman et al., p. 1081)

11 Loss & Death Situational Losses: loss of one’s job, death of a child, or loss of functional ability because of acute illness or injury Types of Death Unexpected death that leaves families feeling shocked & bereaved; Examples might be death due to a heart attack Traumatic death which can lead to complicated grief: Examples: suicide or homicide Anticipated death from a chronic or prolonged illness; families may be physically & emotionally exhausted from caring for the family member prior to death (Berman et al.)

12 Grief, Bereavement, Mourning
Grief: “The total response to the emotional experience to loss” “Grief is manifested in thoughts, feelings, & behaviors associated with overwhelming distress or sorrow” (Berman et al., p. 1082) Bereavement: “The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship” (Berman et al., 1082) Bereavement: “A common depressed reaction to the death of a loved one” (Kochrow & Christensen, p. 190)

13 Grief, Bereavement, Mourning
Mourning: “The behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, & custom” (Berman et al., p. 1082) Mourning: “(reaction activated by a person to assist in overcoming a personal loss) refers to culturally defined patterns for expressions of grief; mourning patterns include funerals, wakes, memorials, black dress, & defined time of social withdrawal” (Kochrow & Christensen, p. 190)

14 Grief, Bereavement, Mourning
Grief & mourning are experienced by the person who faces the death of a loved one AND by the person who suffers other kinds of losses (includes healthcare workers) Grieving is important for one’s physical & mental health Grieving permits individuals to cope with the loss gradually & accept it as part of reality Grief is a social process & is best shared & carried out with the assistance of others (Berman et al., p. 1082)

15 Grief, Bereavement, Mourning
Healthcare workers who work with the terminally ill & bereaved often develop a heightened empathy & identification with their patients This occurs because the loss experience is so universal that everyone has experienced its impact Previous losses can prepare people for the ultimate loss of death Grief is a normal & universal response to loss There are many examples of increased illness or an abnormal condition (both physical & mental) after significant losses in the survivors, especially caregivers Research indicates that there are increases in breakups in marriages & other significant relationships after the loss of a child or when one partner suffers a loss of a body part or function (Kochrow & Christensen, p. 190)

16 Grief, Bereavement, Mourning
Grief involves thought, feelings, & behaviors & has a useful function when allowed to operate normally The goal of the grieving process is to resolve the hurt & to reestablish one’s life Grief comes & goes with a person’s life experiences & many years later an event reminds the person of the loss & the feelings return Such events might include encounters with smells, places, foods, dates, holidays, clothing, music, & other people Grief is not an episode; it is a process, sometimes one that goes on forever (e.g. parents grieving for a child) (Kochrow & Christensen, p. 190)

17 Grief, Bereavement, Mourning
Grieving persons try a variety of strategies to cope Tasks of grief that facilitate healthy adjustment to loss Accepting the reality of the loss Experiencing the pain of grief Adjusting to an environment that no longer includes the lost person, lost object, or the lost aspect of self Reinvesting emotional energy into new relationships The successful completion of these tasks leads to the passage from grief to closure These tasks do not necessarily occur in a specific order or sequence; people may work all tasks of grief at the same time or only one or two may be priorities Healthcare workers can assist patients & their families in working through these tasks (Kochrow & Christensen, p. 190)

18 Grief, Bereavement, Mourning
Working through one’s grief is important because bereavement may have devastating effects on health Symptoms that may accompany grief are: Anxiety, * Excessive sweating Depression * Menstrual disturbances Swallowing difficulties * Palpitations Vomiting * Chest pain Fatigue * Changes in libido Headaches * Alterations in communication Dizziness * Difficulty in concentration Fainting * Disturbances in eating patterns Blurred vision * Alterations in sleeping patterns Skin rashes * Changes in activity Shortness of breath (Berman et al., p. 1082)

19 Types of Grief

20 Grief, Bereavement, Mourning
It’s important to differentiate the expression of grief as a normal healthy response to loss (needs support & public acknowledgement) from grief as a response of greater distress & personal disruption (requires intensive intervention/assistance) There are different types of grief Normal grief Complicated grief Anticipatory grief Disenfranchised grief

21 Grief, Bereavement, Mourning
Although bereavement can threaten health, a positive resolution of the grieving process can enrich the individual with new insights, values, challenges, openness, & sensitivity (Berman et al., p. 1082) There is no right or wrong way to grieve; theories of grief are only tools that can be used to anticipate the emotional needs of patients/families & plan ways to help them understand their grief & deal with it Healthcare workers’ roles are to observe & assess grieving behaviors, recognize the influence of grief on behaviors, & provide empathetic support (Kochrow & Christensen, pp )

22 Normal Grief Normal grief (uncomplicated grief)-most common type of grief) is when grieving people are in the process of coping with the death of a loved one (Potter & Perry, p. 463) Coping styles, such as hardiness & resilience & a personal sense of control, the ability to make sense of the loss, & to find benefit in the loss are factors found to be helpful (Holland & others, as cited in (Potter & Perry, p. 463) Normal grief is a complex response with emotional, cognitive, social, physical, behavioral, & spiritual concepts Feelings of acceptance, disbelief, yearning, anger, & depression were displayed as normal bereavement (Maciejewski & others, 2007 as cited in Potter & Perry, p. 463) Yearning (longing & searching for the deceased person) was the most common negative feeling, peaking at 2 months after the loss; Acceptance was the strongest initial response & grew increasingly over time Negative emotions (anger & depression) peaked around 4 months & were in decline by 6 months (Potter & Perry, p. 463)

23 Complicated Grief For a minority of people, normal grief adjustment does not occur In complicated (dysfunctional) grief, the grieving person has a prolonged or significantly difficult time moving forward from the loss Those with a complicated grief after the loss of a loved one experience a chronic & disruptive yearning for the deceased & are likely to have trouble accepting the death & trusting others, feel excessively bitter, or are uneasy about the future; they may feel emotionally numb This type of grief usually occurs in situations of conflicted relationships with the deceased, prior or multiple losses or stressors, mental health issues, or lack of social support Loss associated with homicide, suicide, sudden accidents, or loss of a child may become complicated Symptoms & disturbances of complicated grief last at least 6 months after a loss & interrupt every dimension of the person’s life (Potter & Perry, p. 463)

24 Anticipatory Grief Anticipatory grief: The unconscious process of disengaging or “letting go” before the actual loss or death occurs, especially in long or predicted loss (Corless, as cited in Potter & Perry, p. 463) When grief extends of a long period of time, people absorb the loss gradually & begin to prepare for the inevitability; they experience more intense responses to grief (shock, denial, tearfulness) before the actual death occurs & often relief when it happens Anticipatory grief may be a forewarning to give families time to prepare for death & to complete related tasks to the impending death (may not apply in every situation though) For some others, the stress & strain of a terminal illness (ruptures in spousal intimacy, separation anxiety, security threats, & traumatic helplessness of watching a loved one die) may outweigh the benefits of anticipatory grieving (Potter & Perry, p. 463)

25 Disenfranchised Grief
People experience disenfranchised grief (known as marginal or unsupported grief) when their relationship to the deceased person is not socially sanctioned, cannot be openly acknowledged or publicly shared, or seems of lesser significance (Hooyman & Kramer, as cited in Potter & Perry, p. 463) Examples include death of a very old person, an ex-spouse, a gay partner, or even a loved pet (Potter & Perry, p. 463)

26 Stages of Grieving/Dying

27 Stages of Grieving/Dying
Kübler-Ross (1969) describes five stages of dying Although these stages are listed in order, grieving people do not experience them in any particular order for any length of time & often move back & forth between stages Five Stages of Dying Denial Stage Anger Stage Bargaining Stage Depression Stage Acceptance Stage (Potter & Perry, p. 464)

28 Stages of Grieving/Dying
Denial & Isolation Stage: a person acts as though nothing has happened & refuses to accept the fact of the loss; person shows no understanding of what has occurred (Potter & Perry, p. 464) This stage serves as a buffer to the patient to shield self until the individual is able to mobilize alternate defenses Reaction: “No-not me.” “There must be a mistake.” (Kockrow & Christensen, p. 193)

29 Stages of Grieving/Dying
Anger Stage of adjustment to loss, a person expresses resistance & sometimes intense anger at God, other people, or the situation (Potter & Perry, p. 464) Hostility may be directed toward caregivers or loved ones Reactions: “Why me?” (Kockrow & Christensen, p. 193)

30 Stages of Grieving/Dying
Bargaining Stage cushions & postpones awareness of the loss by trying to prevent it from happening Bargaining Stage : Grieving or dying people make promises to self, God, or loved ones that they will live or believe differently if they are spared the dreaded outcome (Potter & Perry, p. 193) Bargaining is often made with God. It is an attempt to post pone death & is a positive way to maintain hope Reactions: “Yes, but…….” (Kockrow & Christensen, p. 193)

31 Stages of Grieving/Dying
Depression Stage occurs when a person realizes the full impact of the loss Depression Stage: Some feel an overwhelming sense of sadness, hopelessness, & loneliness; resigned to the bad outcome, they sometimes withdraw from relationships & life (Potter & Perry, p. 464) Sadness & grief; time of introspection; usually request only significant others to be with them The patient struggles with painful realities of life & prepares for death Reactions: “Yes, me.” (Kockrow & Christensen, p. 193)

32 Stages of Grieving/Dying
Acceptance Stage: the person incorporates the loss into life & finds ways to move forward (Potter & Perry, p. 464) Resolved to the fact that death is imminent Peaceful acceptance & positive feelings are often present Reactions: “I am ready.” (Kockrow & Christensen, p. 193)

33 Factors Influencing Loss & Grief Responses

34 Factors Influencing Loss & Grief
Multiple variables influence the way a person perceives & responds to loss Variables are Human developmental factors Personal relationships Nature of the loss Coping strategies Socioeconomic status Cultural influences Spiritual influences (Potter & Perry, pp )

35 Human Developmental Factors
Client’s age & stage of development affect the grieve response Toddlers do not understand loss or death, but feel anxiety & sometimes express the sense of absence with changes in eating & sleeping patterns, fussiness, or bowel & bladder disturbances School-age children understand permanence & irreversibility, but do not understand the causes of a loss; some have intensive emotional expressions (Potter & Perry, pp )

36 Human Developmental Factors
Young adults have developmental losses as they leave home and or form significant relationships; illness or death disrupts one’s future & the necessary tasks of establishing an autonomous sense of self Midlife adults experience major life transitions: caring for aging parents or dealing with their death, dealing with changes in marital status, losses resulting from impaired health or body functions, & adapting to new family roles Response influenced by previous loss experiences, person’ s self-esteem, & strength & availability of support Older adults deal with losses related to the aging process & may have more skills dealing with death learned from multiple previous experiences with loss (Berman et al., p )

37 Personal Relationships
The quality & meaning of the lost relationship (if very close, well-connected) influences the grief Grief resolution may be hampered by regret or a sense of unfinished business when people are closely related but did not have a good relationship at the time of death Social support & the ability to accept help from others are critical variables in recovery from loss & grief If clients do not receive supportive understanding & compassion the grief becomes complicated or prolonged (Potter & Perry, pp )

38 Nature of the Loss Exploring the meaning of the loss for a client helps the healthcare worker understand the impact of loss on client’s behavior, health, & well-being (Corless, as cited in Potter & Perry, p. 466) Highly visible losses generally stimulate a helping response from others, the community, & government, such as homes lost by tornados, but more private losses, such as a miscarriage brings much less support Stressors from a sudden & unexpected death pose different challenges than those anticipated by a debilitating chronic illness In cases of sudden & unexpected death, survivors do not have time to let go In cases of chronic disease & death, survivors have memories of prolonged suffering, pain, & loss of function Death by violence or suicide or multiple losses by their very nature complicate the grieving process in unique ways (Stroebe & Schut, as cited in Potter & Perry, p. 466)

39 Cause of Loss or Death Individual & societal views on the cause of a loss or death may influence the grief response or process Some diseases are considered “clean” & endear compassion while others may be viewed as repulsive & unfortunate A loss or death beyond the control of those involved may be more acceptable than one that is preventable, such as a drunk driver collision Injuries & death occurring during respected activities, such as “in the line of duty” are considered honorable, whereas those occurring during illicit activities may be considered the individual’s just reward (Berman et al., p. 1086)

40 Coping Strategies Life experiences shape coping strategies one uses to deal with the stress of loss One always relies first on familiar coping strategies after a loss; when the usual strategies do not work, one needs new ones Emotional disclosure (venting or talking about one’s feelings) is viewed as an important way to cope with loss Recent research suggests that the focus should be on positive emotions & optimistic feelings rather than negative feelings or the expression of anger associated with the loss for a more successful bereavement coping strategy (Ong & Others, 2004, as cited in Potter & Perry, p. 466) Emotional disclosure is often accompanied by having people write about their feelings (Potter & Perry, p. 466)

41 Socioeconomic Status Socioeconomic status influences a person’s ability to access support & resources for coping with loss & physical responses to stress (Cohen, Doyle, & Baum, as cited in Potter & Perry, p. 466) When people lack financial, educational, or occupational resources, the burdens of loss multiply Example: a client with limited finances is not able to replace a car demolished in a collision & pay for the associated medical expenses (Potter & Perry, p. 466)

42 Culture & Ethnicity One’s culture & other social structures (family or religious affiliation) influence the interpretations of loss, establish expressions of grief, & provide stability & structure amid the chaos & loss) Expressions of grief in one person’s culture may not make sense to persons from another culture Healthcare workers should try to understand & appreciate each client’s cultural values related to loss, death, & grieving American cultural values of individualism & self-determination are in contrast with communal, family, or tribal ways of life

43 Hope Hope: a multidimensional component of spirituality, energizes & provides comfort to individuals experiencing personal challenges Hopefulness gives one the ability to see life as enduring or as having meaning or purpose As a future-shaping, motivating force, hope helps clients maintain anticipation of a continued good, an improvement in their circumstances, or a lessening of something unpleasant; with hope, a client moves from feelings of weakness & vulnerability to living as fully as possible (Arnaert, Filteau, & Sourial, as cited in Potter & Perry, p. 467)

44 Hope Maintaining a sense of hope depends on a person having a strong relationships & emotional connectedness to others Healthcare workers help provide the sense of belonging, which is so essential to hope The experience of spiritual distress often arises from a client’s inability to feel hopeful or foresee any favorable outcomes. Spirituality & hope play a vital role in a client’s adjustment to loss (Potter & Perry, p. 467)

45 Gender Gender roles into which people are socialized in US & Canada affect their reactions at times of loss Men are frequently expected to “be strong” & show very little emotion during grief, whereas it is acceptable for women to show grief by crying Often the when the wife dies, the husband (chief mourner) is expected to repress his own emotions & comfort sons & daughters in their grieving Gender roles also affect the significance of body image changes to clients A man may consider a facial scar to be “macho,” but a woman might consider hers ugly; thus the woman, not the man, would see the change as a loss (Berman et al., p. 1086)

46 Support System People closest to the grieving individual are often the first to recognize & provide the needed emotional, physical, & functional assistance There are many people who are uncomfortable or inexperienced in dealing with losses so the usual people withdraw from the grieving individual Support may be available when the loss is first recognized but as the support people return to their usual activities, the need for ongoing support is unmet Sometimes the grieving individual is unable or unready to accept support when it is offered (Berman et al., p. 1086)

47 Survivor’s Manifestations of Grief & Bereavement

48 Normal Manifestations of Grief
Manifestations of grief that are considered normal include the verbalization of loss, crying, sleep disturbances, loss of appetite, & difficulty concentrating (Berman et al., p. 1084)

49 Survivors’ Manifestations of Grief & Bereavement
According to Martocchio there are five stages of the survivor’s reaction to grief & bereavement: Five Stages of Survivors’ Manifestations of Grief & Bereavement 1. Shock & disbelief 2. Yearning & protest 3. Anguish, disorganization, & despair 4. Identification of bereavement 5. Reorganization & restitution (Kockrow & Christensen, p. 193)

50 Survivors’ Manifestations of Grief & Bereavement
Shock & Disbelief Survivors feel a sense of unreality Often reject offers of comfort & support Disbelief may remain even though death is comprehended intellectually Reactions: “Maybe this is not happening.” “This is just a dream/nightmare.” (Kockrow & Christensen, p. 193)

51 Survivors’ Manifestations of Grief & Bereavement
Yearning & Protest Survivors may express anger toward the deceased for leaving them Reactions: “Why do I feel this way?” Anguish, Disorganization, & Despair Reality & permanency of the loss are recognized Reactions: “Living is a chore.” “All the joy is gone out of life.” (Kockrow & Christensen, p. 193)

52 Survivors’ Manifestations of Grief & Bereavement
Identification in bereavement Bereaved may adopt behavior, ideals, mannerisms, or goals of the deceased: “I will carry on her (dying person’s) goals.” Reactions: “I am just like him (dying or deceased person).” Reorganization & Restitution Life stabilizes but some of the pain of loss may remain for a lifetime Reactions: “Life goes on.” “The sun has risen on a new day.” (Kockrow & Christensen, p. 193)

53 Dimensions of Clients’ Needs

54 Dimensions of Clients’ of Needs
To give compassionate care & support to the family & dying patient during the grieving & dying process, the healthcare worker should consider the five aspects of human functioning: Physical Emotional Intellectual Social Spiritual (Kockrow & Christensen, p. 195)

55 Physical Dimension Review the physical needs, such as sleeping patterns, body image, activities of daily living (ADLs), mobility, general health, & pain What are the basic needs of nutrition, elimination, oxygenation, activity, rest, sleep, & safety (Maslow’s Hierarchy of Needs) Some goals are to provide comfort measures, energy conservation, pain reduction techniques, promotion of sleep & rest, & increasing self-esteem through body image acceptance (Kockrow & Christensen, p. 195)

56 Emotional Dimension Preparing for death is a personal endeavor filled with anxiety & fear Check the patient’s & family’s anxiety level, anger, level of acceptance, & identification Major fears of dying include fears of abandonment (dying alone), loss of control, pain & discomfort, & fears of the unknown Healthcare workers should Accept the patient’s/family’s individual feelings Offer encouragement & support Give the patient “permission to die” by assisting the patient in saying good-bye (Kockrow & Christensen, p. 195)

57 Emotional Dimension Use silence & personal presence along with techniques of therapeutic communication (enhances the exploration of feelings & lets the client know that you acknowledge their feelings) Acknowledge the grief of the client’s family & significant others (family support persons are part of the grieving client’s world) Offer choices that promote client autonomy (client’s have a need of a sense of control over their own lives at a time when much control is not possible) for example: allow the client to choose when she/he wants his bath Provide appropriate information regarding access to resources, such as clergy, support groups, & counseling services (Berman et al., p. 1089)

58 Intellectual Dimension
Consider the patient’s/family’s level of education, their knowledge & abilities, & expectations they have in regard to how & when death will occur There can be changes in the intellectual dimensions during the dying process because of physiological changes, medications, the patient’s emotional state, or the disease process; Be alert to changes if the patient’s memory or if sensations are decreased Provide patient/family education (what they can expect) & support; Keep patient/family informed of procedures, changes in the patient’s condition (check hospital policies for tasks appropriate to your position) (Kockrow & Christensen, p. 195)

59 Social Dimension Check to see what involvement the family wishes to do in providing care of their dying loved one Assisting with the patient’s cares, such as a bath may give the family a sense of control– it is important to check what tasks might be done by the family and what will be done by the healthcare worker Important to make needs & wants clear to improve in trust & reduce hostility between family & healthcare workers Each family & each individual member are unique in what they wish to do so don’t assume, but ask Family is important, but it’s important to learn from the patient whom he/she considers significant others—who does the patient consider the most supportive person in his/her life? (It may be a friend, coworker, or church member (Kockrow & Christensen, p. 195)

60 Spiritual Dimension Healthcare worker should assess the patient’s philosophy of life, religious resources, & how the rituals of the particular faith group have significance in dealing with the patient’s death What are the client’s feelings related to death & dying experiences Do not judge or use tendencies to interpret & analyze; instead create an atmosphere of openness to discuss the patient’s spiritual concerns Resources can come from clergy, friends, family, healthcare providers, & significant others It is important to support the patient’s/family’s belief system & values (Kockrow & Christensen, p. 195)

61 Spiritual Dimension One aspect of the belief system is hope & can take many forms Hope is multidimensional Hope is a common thread in all stages of grief It is characterized by a confident yet uncertain expectation of achieving a goal; it not a single act, but a complex series of thoughts, feelings, & actions that change often The strength of religious connections & performance of family role responsibilities are significantly related to hope & coping (Kockrow & Christensen, p. 195)

62 Spiritual Dimension It is difficult to maintain hope during the dying process As the person’s condition deteriorates, the health care worker assists the family in translating hope of a cure into realistic hopes that are focused on short-term, achievable goals, such as a comfortable & a pain-free life or the decision to live long enough to participate in an important family event, such as a wedding of a child A total loss of hope leads to distress of the human spirit & the relinquishment of hope is rapidly followed by death (Kockrow & Christensen, p. 198)

63 References Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Loss, grieving, & death. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp ). Upper Saddle River, NJ: Prentice Hall Kockrow, O.E. & Christensen, B.L. (2006).Loss, grieving, dying, & death. In B.L. Christensen & E. O. Kockrow (Eds.). Foundations and adult health nursing (5th ed.) (pp ). St. Louis, MO: Elsevier, Mosby Juliar, K. (2003) Minnesota Healthcare Core Curriculum (2nd ed.). Clifton Park, NY: Delmar Publishers Potter, P.A. & Perry, A.G. (2009). The experience of loss, death, & grief. In P.A. Potter & A.G. Perry (Eds.). Fundamentals of nursing (7th ed.) (pp ). St. Louis, MO: Elsevier, Mosby

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